Buzzing, hissing, ringing, swooshing, crackling, clicking, pulsing, roaring, and the list goes on. All descriptions heard from patients complaining of tinnitus, usually a completely subjective description of a presence of noise in the ear/s. If the patient is referred to an ENT, and then sent back with no major finding explaining the tinnitus, what’s the next best step? The intent of this article is to provide a brief review of tinnitus and best practices for tinnitus evaluation, as well as a discussion of tinnitus counseling.
Our patients are not alone. A study by Davis and Refaie in 2000, estimated 10% - 15% of the US population experiences chronic or persistent tinnitus. Several studies have confirmed the relationship between hearing loss and tinnitus (Axelsson & Barrenas, 1992; Davis & Refaie, 2000; and Meikle, 1991). In 2007, Kochkin reported more than 22 million adults with hearing loss in the United States delay or avoid a hearing solution.
As hearing health professionals with a goal of helping patients toward better hearing, it is interesting to note Kochkin went on to report 39% of this population indicated they had not sought help for their hearing loss specifically because they concurrently had tinnitus. With the prevalence of patients hesitant to be seen because of their tinnitus, it is important to have a knowledge of this topic to be prepared to help them when they do seek help.
The American Academy of Audiology offers the following evaluation measures (in addition to the audiologic examination) as best practice:
Comprehensive case history including, but not limited to, questions regarding time of onset, course of progression, description, location, perceived cause, extent to which the patient is bothered, exacerbating factors (such as food, stress, lack of sleep, etc.), history of noise exposure, medications, familial history of hearing loss or tinnitus, effect on sleep, and effect on personal/social/occupational relationships.
- Loudness discomfort levels
- Tinnitus pitch matching
- Tinnitus loudness matching
- Minimal masking level
- Subjective questionnaires; There are several valid and reliable surveys designed to measure the disability and handicap associated with tinnitus
- Professionals that specialize in the assessment and treatment of tinnitus also may find additional audiologic procedures useful for diagnosis and counseling
- American Academy of Audiology (2000)
Although this article will not delve into each of these tests, I felt it important to include the following on loudness discomfort levels. When conducting audiometric testing, it is critical for the clinician to be aware that many tinnitus patients are also hypersensitive to sound. Thus extreme caution must be taken when testing acoustic reflexes, which generally is not advised. (Henry, et al., 2005) On this topic of sensitivity, Henry, et al. (2005) also goes on to discuss the difference between hyperacusis and misphonia by citing a study by M.M. Jastreboff and Jastreboff in 2002:
They described hyperacusis as a condition of hypersensitivity to sound that is restricted primarily to the auditory pathways. Thus, when sound that is normally well tolerated causes physical discomfort, hyperacusis is indicated. Misphonia refers to dislike of sound and involves primarily an emotional reaction that is mediated by the limbic and autonomic nervous systems.
The differentiation between these two conditions is important in determining proper treatment for the patient.
There are various treatment options for tinnitus available to our patients. They include but are not limited to: hearing amplification (most common), psychological treatments, pharmacological approaches, tinnitus masking, tinnitus retraining therapy, TMJ treatment, as well as other more holistic approaches such as use of Ginkgo biloba, or Lipoflavinoids. Regardless of which option a professional chooses for treatment of their patient, there is a constant which should be included in the process, counseling.
Counseling and Expectations
There are a number of common counseling points that are appropriate for all tinnitus patients, such as (a) avoiding high-level noise exposure, (b) making lifestyle changes that would be conducive to minimizing tinnitus intensity (e.g., reducing stress, getting adequate sleep, limiting intake of alcohol, caffeine, tobacco, etc. ), (c) maintaining a constant background of sound (avoiding silence) to reduce the prominence of tinnitus, and (d) staying busy with meaningful activities to distract attention away from the stress. (Henry et al., 2005)
In addition to the basic points of counseling listed above, part of effective counseling also requires a setting of realistic expectations. According to Henry et al. (2005), it is estimated that up to 90% of tinnitus patients may benefit from amplification. However, how quickly might the patient expect to perceive a benefit? If a patient is set up for a one-week amplification trial for example, can we expect that is long enough for the patient to know if they receive a benefit in tinnitus reduction from the amplification?
Surr, Kolb, Cord, and Garrus (1999) conducted a follow-up study on tinnitus patients who had been fit with amplification, using the Tinnitus Handicap Inventory (THI; Newman et al., 1996) prior to amplification, and six weeks following fitting. They found a statistically significant reduction in the mean scores at six weeks after amplification. Since the THI was not administered serially following amplification it’s hard to know when the benefit was first perceived, butthe study does provide a good basis for a timeframe in which we can expect our patients may perceive benefit.
Part of effective counseling could also include giving the patient resources and encouraging them to do their own investigation on their condition. One such resource is the American Tinnitus Association (ATA), which has a website offering tinnitus facts, treatment options, and ideas to minimize the impact of their tinnitus. Finally, it should also be considered the patient may benefit from more extensive counseling we as hearing professionals are not able to offer.
…some tinnitus patients have preexisting psychological problems that can cause exaggerated reactions to tinnitus. Psychologists are clearly well qualified to address these issues, even if they do not have any particular tinnitus expertise. Thus, psychological intervention in general can be helpful to many situations. (Henry et al., 2005)
Earlier in the article, the difference between hyperacusis and misphonia was pointed out. Whereas misphonia is an emotional reaction to sound, it is an example of an attribute which may be best treated by a psychologist. Hyperacusis on the other hand may be best treated through desensitization of the auditory pathways through the use of sound. (Henry et al., 2005) This treatment may be more suitable for an audiologist to perform through amplification.
Although common in our profession, tinnitus is a topic which can’t be addressed with a simple solution. Rather, as professionals we are tasked with investigating the facets of our patients’ conditions and making educated decisions on how to best provide treatment. No matter the treatment, counseling is an important part helping our patients toward relief.
American Academy of Audiology (2000). Audiologic guidelines for the diagnosis & management of tinnitus patients
American Tinnitus Association http://www.ata.org
Axelsson, A., & Barrenas, M. L. (1992). Tinnitus in noise-induced hearing loss. In A. L Dancer, D. Henderson, R. J. Salvi, & R. P. Hamnernik (Eds.), Noise-induced hearing loss (pp. 269-276). St. Louis, MO: Mosby Year Book.
Davis, A., El Refaie, A., (2000). Epidemiology of tinnitus. IN: Tyler, RS, ed. Tinnitus Handbook. San Diego: Singular Publishing Group, 1-24)
Henry, J. A., Dennis, K. C., Schechter, M. A. (2005). General review of tinnitus: prevalence, mechanisms, effects, and management. Journal of Speech, Language, and Hearing Research, 48, 1204-1235.
Jastreboff, M. M., & Jastreboff, P. J. (2002). Decreased sound tolerance and tinnitus retraining therapy (TRT). Australian and New Zealand Journal of Audiology, 24, 74-81.
Kochkin, S. (2007). Hearing loss and its impact on household income. Hearing Journal, 60 (4), 27-43.
Meikle, M. B. (1991). How Tinnitus is related to hearing impairment. In Tinnitus: Assessment and rehabilitation: Papers presented at 3rd Bi-Annual Workshop, 15th-17th March 1991 (pp. 4-6). Melbourne: Australian Association of Audiologists in Private Practice.
Surr, R. K., Kolb, J. A., Cord, M. T., & Garrus, N. P. (1999). Tinnitus handicap inventory (THI) as a hearing aid outcome measure. Journal of the American Academy of Audiology, 10, 489- 495.